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Basic Rx Prescription Information

If any of the information does not apply, do not fill out the corresponding fields of the form. Please contact us if you need help understanding or entering your prescription. Prescription eyewear guide.

Progressive / Bifocal Specific Prescription Information

Segment Height and Pupil Distance (PD) are required and must be measured specifically for the frame you are ordering if you desire perfect fit for your prescription eyewear. Contact us if you have not had these measurements taken.

AddSeg HtDist. PdNear Pd

Right Eye (OD)

Left Eye (OS)

Doctor's Information

Name

Phone Number

Additional Comments & Instructions

This product may be covered by your FSA/HSA plan. If you would like to use your FSA/HSA debit card to purchase an eligible product covered by your account's plan, please give us a call at 800-504-5897 and we will be glad to take your order over the phone. Unfortunately at this time OpticsPlanet is unable to accept FSA/HSA debit cards via our online checkout.

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